Quiz: Sternoclavicular Joint Swelling in a Previously Healthy Adult

Abstract

A 77-year-old woman was admitted to our department because of 30-day history of low grade fever (up to 38.5°C) and pain in the left sternoclavicular joint. Twenty days before admission a progressively worsening swelling of the area occurred. She did not report any trauma and apart from low grade fever, the patient had also general symptoms such as loss of appetite, weakness and malaise. Her past medical history revealed only mild arterial hypertension. The patient had never received any kind of immunosuppression in the past whereas, there was no history of tuberculosis, diabetes mellitus, iv drug abuse, immune dysfunction or other known risk factors which have been associated with the presence of sternoclavicular joint infection (SCJI) [1]. She had been treated previously by her own general practitioner for 10 days before admission with oral beta-lactam antibiotic and cephalosporin without any improvement. On admission, physical examination revealed a dolorous, inflammatory lesion of the left sternoclavicular joint (Figure 1) and movement limitation of the left arm, whereas there was no ascites or peripheral lymphadenopathy. Laboratory work-up showed only moderate elevation of CRP (5.7 mg/dL; upper normal limit < 1 mg/dL), increased erythrocyte sedimentation rate (ESR; 66 mm/1h), positive tuberculin test (20 mm) while chest x-ray was normal. MRI of the area showed mild osteomyelitis of the clavicle and cellulitis of the surrounding tissues with no effusion at SCJ. The CT scans of the thorax, upper and lower abdomen and retroperitoneal space revealed no lymphadenopathy or pulmonary lesions. After drawing several sets of blood cultures, treatment with daptomycin was started at a dose of 8 mg/kg/day. We chose daptomycin as unfortunately in our area the rates of communityand hospital-associated methicillin resistant Staphylococcus aureus (MRSA) infections have been increased from 14.5% in 2000 up to 40-50% in 2006 and 65% in 2007-2009 [2,3]. Therefore, in our practice we usually manage severe infections of soft tissues, bone or spine initially with vancomycin, teicoplanin or daptomycin until a positive culture with sensitivity tests was obtained [4].